Anthony E. Burgos

Importance of Generational Status in Examining Access to and Utilization of Health Care Services by Mexican American Children

Objectives. To describe the sociodemographic differences among Mexican American children (first, second, and third generation), non-Hispanic black children, and non-Hispanic white children; to compare the health status and health care needs of Mexican American children (first, second, and third generation) with those of non-Hispanic black children and non-Hispanic white children; and to determine whether first-generation Mexican American children have poorer health care access and utilization than do non-Hispanic white children, after controlling for health insurance status and socioeconomic status. Methods. The Third National Health and Nutrition Examination Survey was used to create a sample of 4372 Mexican American children (divided into 3 generational groups), 4138 non-Hispanic black children, and 4594 non-Hispanic white children, 2 months to 16 years of age. We compared parent/caregiver reports of health status and needs (perceived health of the child and reported illnesses), health care access (usual source of health care and specific provider), and health care utilization (contact with a physician within the past year, use of prescription medications, physician visit because of earache/infection, and hearing and vision screenings) for different subgroups within the sample. Results. More than two thirds of first-generation Mexican American children were poor and uninsured and had parents with low educational attainment. More than one fourth of first-generation children were perceived as having poor or fair health, despite experiencing similar or better rates of illnesses, compared with other children. Almost one half of first-generation Mexican American children had not seen a doctor in the past year, compared with one fourth or less for other groups. Health care needs among first-generation Mexican American children were lower, on the basis of reported illnesses, but perceived health status was worse than for all other groups. After controlling for health insurance coverage and socioeconomic status, first-generation Mexican American children and non-Hispanic black children were less likely than non-Hispanic white children to have a usual source of care, to have a specific provider, or to have seen or talked with a physician in the past year. Conclusions. Of the 3 groups of children, Mexican American children had the least health care access and utilization, even after controlling for socioeconomic status and health insurance status. Our findings showed that Mexican American children had much lower levels of access and utilization than previously reported for Hispanic children on the whole. As a subgroup, first-generation Mexican American children fared substantially worse than second- or third-generation children. The discrepancy between poor perceived health status and lower rates of reported illnesses in the first-generation group leads to questions regarding generalized application of the “epidemiologic paradox.” Given the overall growth of the Hispanic population in the United States and the relative growth of individual immigrant subgroups, the identification of subgroups in need is essential for the development of effective research and policy. Furthermore, taking generational status into account is likely to be revealing with respect to disparities in access to and utilization of pediatric services.

Readmission for Neonatal Jaundice in California, 1991–2000: Trends and Implications

OBJECTIVE. We sought to describe population-based trends, potential risk factors, and hospital costs of readmission for jaundice for term and late preterm infants. METHODS. Birth-cohort data were obtained from the California Office of Statewide Health Planning and Development and contained infant vital statistics data linked to infant and maternal hospital discharge summaries. The study population was limited to healthy, routinely discharged infants through the use of multiple exclusion criteria. All linked readmissions occurred within 14 days of birth. International Classification of Diseases, Ninth Revision, codes were used to further limit the sample to readmission for jaundice. Hospital discharge records were the source of diagnoses, hospital charges, and length-of-stay information. Hospital costs were estimated using hospital-specific ratios of costs to charges and adjusted to 1991. RESULTS. Readmission rates for jaundice generally rose after 1994 and peaked in 1998 at 11.34 per 1000. The readmission rate for late preterm infants (as a share of all infants) over the study period remained at <2 per 1000. Factors associated with increased likelihood of hospital readmission for jaundice included gestational age 34 to 39 weeks, birth weight of <2500 g, male gender, Medicaid or private insurance, and Asian race. Factors associated with a decreased likelihood of readmission for jaundice were cesarean section delivery and black race. The mean cost of readmission for all infants was

Effect of Early Limited Formula on Duration and Exclusivity of Breastfeeding in At-Risk Infants: An RCT

2764, with a median cost of

Discrepancies Between Transcutaneous and Serum Bilirubin Measurements

1594. CONCLUSIONS. Risk-adjusted readmission rates for jaundice rose following the 1994 hyperbilirubinemia guidelines and declined after postpartum length-of-stay legislation in 1998. In 2000, the readmission rate remained 6% higher than in 1991. These findings highlight the complex relationship among newborn physiology, socioeconomics, race or ethnicity, public policy, clinical guidelines, and physician practice. These trend data provide the necessary baseline to study whether revised guidelines will change practice patterns or improve outcomes. Cost data also provide a break-even point for prevention strategies.

Readmission for Newborn Jaundice: The Value of the Coombs’ Test in Predicting the Need for Phototherapy

BACKGROUND AND OBJECTIVES: Recent public health efforts focus on reducing formula use for breastfed infants during the birth hospitalization. No previous randomized trials report the effects of brief early formula use. The objective of the study was to determine if small formula volumes before the onset of mature milk production might reduce formula use at 1 week and improve breastfeeding at 3 months for newborns at risk for breastfeeding problems. METHODS: We randomly assigned 40 exclusively breastfeeding term infants, 24 to 48 hours old, who had lost ≥5% birth weight to early limited formula (ELF) intervention (10 mL formula by syringe after each breastfeeding and discontinued when mature milk production began) or control (continued exclusive breastfeeding). Our outcomes were breastfeeding and formula use at 1 week and 1, 2, and 3 months. RESULTS: Among infants randomly assigned to ELF during the birth hospitalization, 2 (10%) of 20 used formula at 1 week of age, compared with 9 (47%) of 19 control infants assigned during the birth hospitalization to continue exclusive breastfeeding (P = .01). At 3 months, 15 (79%) of 19 infants assigned to ELF during the birth hospitalization were breastfeeding exclusively, compared with 8 (42%) of 19 controls (P = .02). CONCLUSIONS: Early limited formula may reduce longer-term formula use at 1 week and increase breastfeeding at 3 months for some infants. ELF may be a successful temporary coping strategy for mothers to support breastfeeding newborns with early weight loss. ELF has the potential for increasing rates of longer-term breastfeeding without supplementation based on findings from this RCT.

Variation in sepsis evaluation across a national network of nurseries

OBJECTIVE: To characterize discrepancies between transcutaneous bilirubin (TcB) measurements and total serum bilirubin (TSB) levels among newborns receiving care at multiple nursery sites across the United States. METHODS: Medical records were reviewed to obtain data on all TcB measurements collected during two 2-week periods on neonates admitted to participating newborn nurseries. Data on TSB levels obtained within 2 hours of a TcB measurement were also abstracted. TcB – TSB differences and correlations between the values were determined. Data on demographic information for individual newborns and TcB screening practices for each nursery were also collected. Multivariate regression analysis was used to identify characteristics independently associated with the TcB – TSB difference. RESULTS: Data on 8319 TcB measurements were collected at 27 nursery sites; 925 TSB levels were matched to a TcB value. The mean TcB – TSB difference was 0.84 ± 1.78 mg/dL, and the correlation between paired measurements was 0.78. In the multivariate analysis, TcB – TSB differences were 0.67 mg/dL higher in African-American newborns than in neonates of other races (P < .001). The TcB – TSB difference also varied significantly based on brand of TcB meter used and hour of age of the infant. For 2.2% of paired measurements, the TcB measurement underestimated the TSB level by ≥3 mg/dL. CONCLUSIONS: During routine clinical care, TcB measurement provided a reasonable estimate of TSB levels in healthy newborns. Discrepancies between TcB and TSB levels were increased in African-American newborns and varied based on brand of meter used.

Screening and Follow-Up for Neonatal Hyperbilirubinemia A Review

Current practice at our hospital is to perform a direct antiglobulin test (DAT) on cord blood samples of all infants born to blood type O or Rh-negative mothers. Measurement of serum total bilirubin (STB) level and follow-up after discharge are at the discretion of the individual physician. The purposes of the present study were, first, to determine the clinical utility of performing a routine DAT and, second, to define the clinical characteristics of infants readmitted to the hospital for phototherapy. The study was done over a 1-year period extending from January 1 to December 31, 2000. A retrospective review of the DAT results of all infants born to type O or Rh-negative mothers was conducted. The 2 groups of infants included those who had a positive cord blood DAT and were treated with phototherapy and those who needed readmission to the hospital for phototherapy. We found that routine DAT testing of cord blood from term nonjaundiced infants born to O positive mothers is not necessary. Infants with 2 or more risk factors for jaundice irrespective of the results of the DAT are at an increased risk for needing readmission for phototherapy.

Prioritizing a research agenda: a Delphi study of the better outcomes through research for newborns (BORN) network.

Variation exists in risk assessment of early onset sepsis that impacts the level of medical intervention and frequency of mother-infant separation among well-appearing term newborns. BACKGROUND AND OBJECTIVES: The extent to which clinicians use currently available guidelines for early-onset sepsis (EOS) screening has not been described. The Better Outcomes through Research for Newborns network represents 97 nurseries in 34 states across the United States. The objective of this study was to describe EOS risk management strategies across a national sample of newborn nurseries. METHODS: A Web-based survey was sent to each Better Outcomes through Research for Newborns network nursery site representative. Nineteen questions addressed specific practices for assessing and managing well-appearing term newborns identified at risk for EOS. RESULTS: Responses were received from 81 (83%) of 97 nurseries located in 33 states. Obstetric diagnosis of chorioamnionitis was the most common factor used to identify risk for EOS (79 of 81). Among well-appearing term infants with concern for maternal chorioamnionitis, 51 of 79 sites used American Academy of Pediatrics or Centers for Disease Control and Prevention guidelines to inform clinical care; 11 used a published sepsis risk calculator; and 2 used clinical observation alone. Complete blood cell count (94.8%) and C-reactive protein (36.4%) were the most common laboratory tests obtained and influenced duration of empirical antibiotics at 13% of the sites. Some degree of mother–infant separation was required for EOS evaluation at 95% of centers, and separation for the entire duration of antibiotic therapy was required in 40% of the sites. CONCLUSIONS: Substantial variation exists in newborn EOS risk assessment, affecting the definition of risk, the level of medical intervention, and ultimately mother–infant separation. Identification of the optimal approach to EOS risk assessment and standardized implementation of such an approach could affect care of a large proportion of newborns.

Utility of Decision Rules for Transcutaneous Bilirubin Measurements

The term hyperbilirubinemia describes an excess of bilirubin in the blood. This becomes clinically apparent as jaundice, a yellow coloration of the skin and whites of the eyes, which occurs in newborns at serum bilirubin levels >5 mg/dL. Hyperbilirubinemia is caused both by increased production of bilirubin as the heme in red blood cells is broken down and by decreased bilirubin excretion due to inadequate hepatic conjugation and increased enterohepatic reabsorption. Jaundice is common: When carefully sought it may be noted in up to 80% of newborn infants. The clinical importance of hyperbilirubinemia derives primarily from its potential to cause kernicterus, a form of brain damage that can cause death or long-term sequelae, including cerebral palsy and hearing loss. Whereas hyperbilirubinemia and resultant jaundice are common, hyperbilirubinemia severe enough to cause kernicterus is rare. Population-based studies of its incidence have only recently become available. Estimates in developed countries range about from about 0.4 to 2 per 100 000 (Table 1). Case series from referral hospitals suggest that the incidence may be much higher in developing countries, at least partly because of higher rates of glucose 6-phosphate dehydrogenase (G6PD) deficiency and sepsis. Lower levels of hyperbilirubinemia may also have some significance as a predictor of outcomes other than kernicterus in very premature infants; however, this area is still under active investigation. For the purposes of this review, we will focus on hyperbilirubinemia in term and late preterm infants. Treatment options for hyperbilirubinemia include exchange transfusion, phototherapy, and replacing breastfeeding with formula. Exchange transfusion consists of replacing a portion of the newborn’s blood with donor blood. This treatment has significant morbidity and mortality and is generally reserved for the most severe cases of hyperbilirubinemia. Phototherapy with light of wavelength in the 430 to 490 nm spectrum is much safer than exchange transfusion, although it leads to expense and separation of mother and infant. In addition, in vitro studies and some epidemiologic studies suggest the as yet unconfirmed possibility of late adverse effects. Rehospitalization for jaundice, which almost always includes phototherapy, occurs in 1% to 2% of all newborns, at an average cost of more than

Hyperbilirubinemia guideline adherence in Russia illustrates universal challenges

3000 per admission (in 2008). Although population-based data on the frequency of exchange transfusion are not available, there has been a significant decline in use of exchange transfusions. Surveys of pediatricians indicate significant variability in the bilirubin levels at which exchange transfusion and phototherapy are recommended. This article reviews current evidence and recommendations for screening and follow-up for neonatal hyperbilirubinemia. Because most of the research and guidelines relate to total bilirubin, we focus on total bilirubin levels with the understanding that significant or prolonged elevation of bilirubin levels should trigger additional evaluation, including fractionation. The 2 main types of bilirubin measurements used clinically—total serum bilirubin (TSB) and transcutaneous bilirubin (TcB)— are discussed in the accompanying boxed feature. Recommendations for treatment with phototherapy or exchange transfusion are not discussed but can be found in the American Academy of Pediatrics (AAP) guideline, or a guideline with similar recommendations (accompanied by a massive evidence synthesis) produced by the United Kingdom’s National Institute for Health and Clinical Excellence (NICE).